- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $302.00 / $588.84
| Professional | | $213.80 | $302.00 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $58.88 / $102.33
| Professional | 26 | $41.69 | $58.88 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $257.04 / $489.78
| Professional | TC | $173.78 | $257.04 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $489.78 / $489.78
| Professional | | $398.11 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $81.28 / $81.28
| Professional | 26 | $66.07 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $331.13 / $407.38 / $407.38
| Professional | TC | $331.13 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $478.63 / $602.56
| Professional | | $281.84 | $478.63 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $77.62 / $102.33
| Professional | 26 | $47.86 | $77.62 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $398.11 / $501.19
| Professional | TC | $234.42 | $398.11 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $562.34 / $1,071.52
| Professional | | $275.42 | $562.34 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $89.13 / $154.88
| Professional | 26 | $50.12 | $89.13 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $467.74 / $891.25
| Professional | TC | $229.09 | $467.74 | $891.25 |